Healthcare Provider Details

I. General information

NPI: 1700843513
Provider Name (Legal Business Name): SOUTHEASTERN INTERVENTIONAL PAIN PHYSICIANS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 MARY ESTHER BLVD SUITE 303
MARY ESTHER FL
32569-1972
US

IV. Provider business mailing address

PO BOX 699
GULF BREEZE FL
32562-0699
US

V. Phone/Fax

Practice location:
  • Phone: 850-243-7788
  • Fax: 850-243-7738
Mailing address:
  • Phone: 850-243-7788
  • Fax: 850-243-7738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA NEWSOM
Title or Position: MEDICAL BILLER
Credential:
Phone: 850-243-7788